Systems Leadership Project to Address Patient Falls
Most Healthcare organizations deploy varied approaches to ensuring that the safety of their patients is guaranteed and the quality of care improved. Systems leadership is one of the healthcare improvement models which involves healthcare practitioners understanding that the organization is a system and that the attainment of health care goals is based on the contribution of all relevant stakeholders (Warren et al., 2016). One of the areas where system leadership is majorly required is the inpatient department. Notably, the increasing number of patient falls in the inpatient department calls for the nursing leaders to deploy systems leadership in ensuring that the rates of falls are reduced, and the safety of the patients provided. According to Barach (2016), all key stakeholders should understand their mandates and undertake them efficiently and in collaboration with others to ensure that the problem of patient falls is addressed. This paper provides a discussion of the issue of patient falls in an oncology facility as well as the significance of the problem. Additionally, a literature review will be conducted, and a gap identified regarding the research done on patient falls in the oncology department. The role of the author as a DNP in addressing the problem will then be demonstrated. Finally, the key stakeholders in the chosen hospital who support and resist proposed changes to solve the issue will be presented.
- Problem Identification
Estimates of patient falls have demonstrated that their rates vary between 700,000-1million in the United States every year (Ganz et al., 2013). Some of the issues which have been associated with the fall incidences are high rates of rehospitalizations due to bone fractures lacerations, and internal bleeding. According to Gu et al. (2016), the primary categories of falls include accidentals falls, the expected physiological falls, and unanticipated physiological ones. In the case of patients with cancer, there is an enhanced risk of falls due to some of the treatment offered (such as androgen deprivation therapy) which result in functional and physical impairments (Overcash, Rivera, & Van Schaick, 2010). For older patients with cancer, the incidences of falls are profound. For instance, according to Overcash, Rivera, & Van Schaick, (2010), 33% of all people in the United States aged 65 years and above have experienced incidences of falls. Out of that number about 16,000 of the same age bracket have died due to injuries arising from falls annually. Zecevic t al. (2012) add that the risk of those aged 65 years and above falling is double the rate of younger patients. The resultant effects of such falls can either be zero injuries, minor, moderate, or severe injuries. In extreme situations, falls result in fatalities. Wildes et al. (2015) underscore the relationship of age of patients with risk of falls by stating that older adults have more experiences with falls as they have specific individual factors. Apart from age, the general percentage of patients who fall varies based on the hospital ward in which they are hospitalized. In particular, Zecevic t al. (2012) states that 53 percent all falls occur in the medical departments.
- Significance of Problem
The problem of patient falls requires various leadership elements including teamwork, collaboration, and vision. The reason for such factors is that patient falls are not necessary just for the healthcare facilities but also for the patients, their families, and caregivers. Some of the issues which have been associated with falls include increased costs of hospitalization, reduced HCAHP scores, and costs involved in litigations. Patient falls related to the areas of leadership and finance as well as economics based on the values which arise from them. According to Zecevic t al. (2012), the average cost for a fall in Canada was $8,374 while the total costs for such falls for the year 2000-2001 were $911 million. However, the Joint Commission. (2015) estimated the average value for a fall with injury to be about $14,000. According to Overcash, Rivera, & Van Schaick (2010), annually, the United States spends an average of $19 billion on catering for the treatment of fall-related injuries. The costs are even higher for patients with cancer considering the unique nature of such patients. Apart from the costs which have been associated with patient falls, they have also resulted in various injuries which might reduce the quality of life for the patients. Notably, according to Ganz et al. (2013), most of the falls can result in various adverse effects including fractures and lacerations. Additionally, they can also lead to internal bleeding and increased healthcare utilization. Moreover, patient falls have been seen to lead to a prolonged hospital stay. According to the Joint Commission (2015), one of the studies conducted established that patients who experience falls need additional treatment which results in added 6.3 days to the stay in a hospital. Additionally, from 2008 the Centers for Medicare & Medicaid Services (CMS) started declining to reimburse hospitals for specific traumatic injuries which may arise when the patient is already hospitalized. Many of the excluded traumatic fractures occur after a fall. As such, high rates of patient falls are costly to the hospitals.
Being a transformational nurse leader would be essential as it would ensure that the HCAHP scores of the healthcare facility would increase due to decrease rates of falls. Patients will only be satisfied with the quality of care if they are assured of their safety. In the oncological department, due to nature of the patients, there are increased rehospitalizations when patients experience falls. Some of the interventions which have been used in the prevention of patient falls include expanding the nursing staff composition. Notably, the more nurse-to-patient ratio could result in the reduction of the incidence of falls. Bearing in mind the mission of the organization of ensuring highest standards of quality care and safety of the patients, it is critical that the aspects of the patient falls be addressed. Addressing the patient falls would result in increased patient and staff satisfaction. Additionally, the healthcare facility would be ranked among the best and become a center of excellence (COE). Moreover, increase revenues will be realized considering that more patients would be satisfied with being hospitalized in such a facility. The costs of litigation are very high for patients who feel that there was some negligence which resulted in their falls. Increasing the patient-staff ratio in the facility so that there is closer monitoring is vital. Alternatively, the hospital can deploy bedside reporting, and hourly rounding techniques which have been seen to affect the rates of patient falls positively. Failure to address the problem of patient fall would lead to reduced patient, and staff satisfaction increased healthcare costs, prolonged hospital stays, and a general decline in the quality of care which are aspects addressed through collaboration among nursing leadership, finance, and economics.
- Literature Review
Patient falls have been defined as undesired events which have the effects of making a patient come to rest unintentionally on either the ground or any other lower surface (Gu et al., 2016). The causes for the falls can be categorized in three groups of accidental, anticipated physiological, and unanticipated physiological falls. Unintentional falls are those who are experienced by people who are not at any risk of falls but who would experience falls due to either the environment of other operational issues. Anticipated physiological falls are those related to the physiology of the patient including their ages, nature of medications, medications as well as medical procedures. Due to the age of the patients as well as their ailments, it becomes easier to anticipate the falls and hence take measures to prevent them. Although unanticipated physiological falls will arise due to physiological reasons, they are unforeseen because standard risk assessments do not identify them. Ganz et al. (2013) classify the causes of the falls based on the results of the falls. Some of the resultant effects of falls identified include lacerations, fractures, and internal bleeding. However, the Joint Commission (2015) argue that the most common contributing factors to fall incidences include lack of adequate protocols, procedures, and safety protocols, lack of leadership, and inadequate assessment of the risks for patient falls. Overcash, Rivera, & Van Schaick (2010) assert that one of the risk factors for the falls is old age and the ailments of the patients. In specific, diagnosis of cancer coupled with old age (65 years and above) has been demonstrated to result in a high vulnerability for patient falls.
The Joint Commission (2015) states that the increasing number of falls should be met with quality improvement efforts. Some of the strategies which have been seen to result in reduced incidences of falls include leadership whereby efforts are put to raise awareness of the need for fall prevention and the avoidance of injuries. Additionally, establishing interdisciplinary fall injury prevention teams will result in reduced number of falls. Moreover, having an efficient mechanism for assessment of the risk of falls is key to preventing them. Gu et al. (2016) agree with the Joint Commission (2015) on the point that the most critical aspect which can lead to the reduction of falls in the application of patient risk assessment. The reason for this is because risk assessment allows the nursing team to dedicate their efforts as well as additional attention to those patients who are at high risk of falling. Overcash, Rivera, & Van Schaick (2010) is also in agreement that reducing patient falls can be ensured trough fall risk assessment. Some of the factors which should be considered during the fall risk evaluation and assessment include the history of events which surround the falls, medications, comorbid conditions, as well as any other health events which make the patients vulnerable to falls. However, Haines et al. (2013) differ by stating that the provision of patient dedication is the most efficient means of prevention as patients know best what they need to ensure their safety and comfort. The Joint Commission (2015) argues that some of the challenges in fall prevention include the absence of interdisciplinary approaches to care as well as lack of support and presence of restraints. Additionally, a low number of staff prevents any efforts aimed at fall prevention.
Most of the studies examined have only considered the concept of patient falls in the inpatient settings and not on specific departments such as the oncology department. Allan-Gibbs (2010) conducted a literature search using various sites such as CINAHL®, PubMed, MEDLINE®, and PsycINFO databases. Out of the multiple studies examined, the author established that only a few studies had investigated fall prevention strategies specifically for those patients who have cancer. Additionally, most of the reviews are concentrated with conducting the fall instances and prevention strategies in the inpatient department. The same observation was made by Wildes et al. (2015) who set out to do a literature review of the available medical literature which examined the various factors associated with falls in older adults who have cancer. It was the findings of the authors that only a few studies have focused on the study of fall incidences and protective mechanisms in the oncological department. Overcash et al. (2010) agreed with the other authors that there is no great deal of research which focused on the falls specific to patients with cancer and those who have been hospitalized in the oncology department. The absence of research on the aspect of patient falls in the oncology department calls for further studies to be conducted on the specific area not only to identify the incidences of falls and their effects, but also the best mechanisms which can be used in the prevention of such falls. Failing to conduct such a study will leave the area ignored which might result in more fall incidences and adverse effects arising from such falls. As a matter of necessity, studying patients falls in the oncology department, and the effectiveness of low nurse-patient ratio in preventing them is key to obtaining concrete information on the area.
- My Role as A DNP
Various vital challenges existing in the oncology facility with relation to patient falls will serve to enhance the acceptance of the project for the lowering of the nurse-patient ratio in the prevention of patent falls. According to Barach (2016), some of the challenges which will enhance the acceptance are those related to the high number of falls in the oncology department, aging populations, and an influx of new and improved therapies. The challenges will ensure that the healthcare facility adopts the project so that the issues arising from the falls can be addressed. However, there are other factors which would cause resistance from the project. One of the factors which would result in the project implementation facing opposition is the cost of the project as well as pending workfare shortage (Barach, 2016). Notably, for the plan to be implemented, finances are required for the deployment of personnel which might not sit well with the management. Opinions might be divided on the costs benefit analysis results of the project as there might be little benefits in the short-term. As such, it is likely that some of the stakeholders such as the management of the oncology facility might resist the project. However, the resistance will be mitigated by the fact that the project would benefit the healthcare facility through reduced fall rates and improved patient outcomes which will ultimately lead to a high number of clients. The organization’s climate will also be critical in supporting the proposed changes. Notably, Barach (2016) opines that the climate of a facility refers to the ways that the workers experience the culture of the institution. The oncology facility in question has shared assumptions and beliefs which guide staff members into ensuring that they improve the quality of care. As such, the climate of embracing change meant to provide improved patient outcomes would be crucial to the success of the changes.
Some essential leadership skills will be critical in ensuring that the proposed changes of reducing the nurse-patient ratio will be smooth and devoid of high scales of resistance. As a DNP, I will need to build trust with other people who will be critical in the change process. Additionally, the collaboration will be vital in ensuring that critical stakeholders actively participate in the change process. Personal resilience will be an essential skill which will entail the provision of support to my colleagues, peers, and even senior managers to make the change process efficient (Fischer, 2017). Networking will ensure that trust is built with other stakeholders and hence implement the change details effectively. Excellent coaching skills will be vital to the line managers so that they can deal with the challenges which face and how they can also maintain personal resilience (Barach, 2016). The skill of organization and which involves creating a sensible plan will not only result in an organized change process but also become a driver of confidence. Listening skills are crucial as the change process will be interdisciplinary. As a DNP, according to Fischer (2017), I will have to possess excellent listening and communication skills so that there can be harmony and understanding in the process of change. Planning the politics of change will be essential considering that there are competing agendas and interests. As such, as a DNP, I will need to reduce uncertainty, broker deals, and ensure that I check my ego which then would increase the probability of success of the changes. Finally, Barach (2016) posits that perseverance will be critical because as a leader of transformational change, I will face different challenging situations in the change process.
- Key Stakeholders
The proposed changes in the oncology facility will be faced with support as well as resistance. Some of the key stakeholders who will support the proposed changes are the nursing staff, patients, and their families. Notably, Barach (2016) states that those who are directly affected by the incidence of falls are the patients. As such, they will support the proposed changes to ensure that the rates of falls are reduced and that their safety is guaranteed. Allen (2016) adds that the support of the patients will be based on the fact that lowering the nurse-patient ratio will result in increased attention to the patients which might translate to better care. The families of the patients will also support the changes as they will be sure that their patients are not only safe but will also receive the most appropriate quality of care. As such, they will join the patients in supporting the changes. The nurse practitioners will also be supportive of the changes for various reasons. Notably, Barach (2016) posits that the nurses are overwhelmed by the needs of the patients especially if their ratio to the patients is very high; as such, the proposed changes will be a sigh of relief as their assignments will be reduced.
The only likely stakeholders who might be opposed to the proposed changes are the management of the oncology facility. The resistance will be based on the cost implications of the proposed changes. Notably, according to Allen (2016), in implementing a project for the prevention of patient falls through increasing the number of staff, the costs might be very high. The organization will first have to be involved in the process of advertising for the vacancies in the various forms of social and print media. Additionally, the process for the selection and recruitment world start for the new staff members. Due to the current high nurse-patient ratio in the healthcare facility, some nurses will need to be hired. As such, Barach (2016) asserts that the organization will have to part with the tremendous amount of resources regarding finances to facilitate the implementation of the proposed changes. For instance, the management of the oncology facility will have to consider the cost of the salaries, bonuses, and allowances for the employees in the long term (Allen, 2016). Therefore, there is a high likelihood that the management will be opposed to the changes on the ground that the project will be costly.
About the patient falls in the oncology department, the stakeholders who will have the most significant positive influence are the patients. Notably, when the rates of satisfaction for the patients are low due to the falls, then the proposed changes will be a necessity. Additionally, the management of the organization and especially the finance department will have a significant say on the changes to the patient falls. Specifically, Spetz et al. (2015) assert that they will have to state whether the project is beneficial or not based on the analysis of the costs that will be incurred and the benefits that the proposed changes would bring to the facility. However, as a DNP, I will have to work with all the stakeholders in the change process irrespective of whether they support or oppose the changes. One of the ways of working will all of them are consulting them and convincing them of the importance of the changes (Barach, 2016). For those resisting, I will conduct a cost-benefit analysis for them and demonstrate the long-term benefits of the changes.
In conclusion, the problem of patent falls in the inpatient department of an oncology facility is very critical considering that cancer patients are vulnerable due to their ailing conditions and medications. Patient falls are costly to healthcare facilities and result in prolonged hospital stay and rehospitalizations. The review of the literature has revealed that few studies have focused on patient falls for patients with cancer. Additionally, few studies have focused on the effectiveness of reducing staff-patient ratio in the prevention of patient falls. The proposed research will, therefore, seek to fill this gap by investigating the efficacy of the reduction of the nurse-patient comparison in the prevention of patient falls in the oncology department. The proposed changes will face support from the patients, their families, and nursing staff. However, they might be opposed by the finance department and the management of the oncology facility. However, as a DNP, I will work with all those stakeholders by demonstrating to them the importance of the changes and how they will be beneficial to the facility.
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